Marquette

Based on interview and record review, the facility failed to provide written notices of discharges to resident representatives or notices to the ombudsman for 3 of 3 residents reviewed for hospitalization and discharge. (Resident 3, 58 and 60) The deficient practice was corrected on 1/16/26, prior to the start of the survey, and therefore was past noncompliance.Findings include:1. The clinical record for Resident 3 was reviewed on 1/29/26 at 9:32 a.m. The diagnoses included, but were not limited to, pneumonia, atrial flutter, acute respiratory failure with hypoxia, malignant neoplasm of colon, and obstructive and reflux uropathy.A nursing progress note, dated 5/30/25 at 7:37 a.m., indicated the resident was transferred to the emergency room at 6:30 a.m. and the daughter was notified verbally. The note did not indicate the daughter received a written notice at any point after the transfer.During an interview, on 2/2/26 at 3:18 p.m., the Social Services Director indicated the facility went over transfers in the morning meeting and discussed people who were sent out. They brought the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNOC) document and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) document prior to the end of service date for 1 of 3 residents reviewed for beneficiary notification. (Resident 44) Findings include: The NOMNOC and SNF ABN documents for Resident 44 were reviewed on 2/4/25 at 8:50 a.m. a. The NOMNOC document indicated Resident 44's Medicare Part A coverage of services would end on 8/22/24 and Medicare would not pay for the current Medicare skilled services after the date of 8/22/24. The document indicated Resident 44 had the right to request an appeal. The appeal would need to be requested no later than noon of the day before the effective end of service date of 8/22/24. Resident 44 was provided with the NOMNOC document on 9/9/24, 13 days after the end of service date. b. The SNF ABN document indicated Resident 44's Medicare Part A Skilled coverage of services would end on 8/21/24 and beginning on 8/23/24, the services of Physical Therapy and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure privacy was provided during a medication administration for 1 of 1 resident reviewed for privacy. (Resident 19) Findings include: During an observation, on 1/30/25 at 10:41 a.m., Resident 19 was sitting in a wheelchair on her side of a shared room. QMA 5 was observed to administer eye drops to Resident 19. The privacy curtain had not been pulled to obscure the view of a visitor on the other side of the shared room. The visitor had an unobstructed view of the care being provided to Resident 19. At that time, QMA 5 indicated the privacy curtain should have been closed when providing all care. During an interview, on 2/4/25 at 3:19 p.m., the Director of Nursing indicated the facility followed the state and federal regulations. A current facility policy, titled Resident Rights, dated as revised in February 2021 and received from the Director of Nursing on 1/31/25 at 8:55 a.m., indicated .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure care plan meetings were scheduled with the resident and/or resident's representative for 2 of 8 residents reviewed for care plan meetings. (Resident 36 and 37) Findings include: 1. During an interview, on 1/30/25 at 10:33 a.m., a family member for Resident 36 indicated they had not attended a care plan meeting for a year. The clinical record for Resident 36 was reviewed on 2/3/25 at 9:11 a.m. The diagnoses included, but were not limited to, severe dementia with mood disturbance, major depressive disorder, and mood disorder. The last documented care plan meetings were held on 3/14/24 and 6/28/24. 2. During an interview, on 1/30/25 at 10:29 a.m., a family member for Resident 37 indicated they had not had a care plan meeting in a year. The clinical record for Resident 37 was reviewed on 2/3/25 at 9:15 a.m. The diagnoses included, but were not limited to, age-related physical debility, constipation, and pain. The last documented care plan meeting was held on 5/6/24. During an interview, on 2/3/25 at 9:12 a.m., the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the physician was notified when blood sugars were out of the physician ordered parameters for 1 of 1 resident reviewed for quality of care. (Resident 34) Findings include: The clinical record for Resident 34 was reviewed on 2/3/25 at 1:32 p.m. The diagnoses included, but were not limited to, type 2 diabetes, edema, and chronic kidney disease. A physician's order, dated 7/8/24, indicated to obtain Accu Checks (blood sugar checks) 4 times a day and to call the physician when the blood sugars were less than 70 or greater than 400. A review of Resident 34's blood sugars indicated the following results: On 12/18/24, the resident's blood sugar was 69. On 12/28/24, the resident's blood sugar was 65. On 12/28/24, the resident's blood sugar was 425. On 1/5/25, the resident's blood sugar was 51. There was no documentation the physician was notified of the blood sugars which were out of the physician ordered parameters found in the resident's record. During an interview, on 2/4/25 at 3:18 p.m., the Director of Nursing (DON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure staff obtained a resident's weight weekly to monitor for weight loss according to the physician's order and to correctly document the weights in the medical record for 1 of 3 residents reviewed for nutrition. (Resident 8) Findings include: The clinical record for Resident 8 was reviewed on 2/4/25 at 1:29 p.m. The diagnoses included, but were not limited to, Barrette's esophagus, anorexia, and nutritional deficiency. A nutritional note, dated 9/12/24, indicated the Registered Dietitian (RD) recommended to begin weekly weights for closer weight loss monitoring. A progress note, dated 9/12/24, indicated a new order had been placed for weekly weights. A physician's order indicated Resident 8 was to be weighed weekly in the morning, every Monday, for weight loss starting 9/16/24. A nutritional note, dated 11/7/24, indicated the RD would continue weekly weights for closer monitoring and would follow up with Resident 8's intakes, weekly weights, and labs as available. The resident's medical record was missing documentation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a physician's order was clear and accurate related to the correct oxygen liter flow rate for 1 of 2 residents reviewed for respiratory care. (Resident 10) Findings include: During an observation, on 1/31/25 at 9:58 a.m., Resident 10's oxygen flow rate was on 2-liters. The clinical record for Resident 10 was reviewed on 2/3/25 at 1:30 p.m. The diagnoses included, but were not limited to, chronic obstructed pulmonary disease (COPD), chronic respiratory failure, and essential hypertension. A physician's order, dated 1/8/25, indicated the oxygen flow rate was to be at 4 liters per minute via nasal cannula. The order summary indicated the oxygen flow rate was to be at 2 liters per minute via nasal cannula. The order had 2 different oxygen liter flow rates. During an interview, on 2/3/25 at 1:48 p.m., Licensed Practical Nurse (LPN) 3 indicated the oxygen order was not a titration order. She thought the resident was to be on 4 liters but did not see the 2 liters listed in the order summary. She would have to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a two (2) handle cup was available for a resident's coffee for 1 of 1 resident reviewed for adaptive equipment. (Resident 1) Findings include: During an observation of the morning meal, on 2/3/25 at 8:35 a.m., Resident 1 was observed in the dining room. She had two handle cups for her milk, juice and water with lids, but an insulated cup with only one handle for coffee. During an interview, on 2/3/25 at 8:25 a.m., the Dietary Manager (DM) indicated she was aware the resident needed two (2) handle cups for her drinks, but she did not think about the coffee and the facility did not have a two-handle insulated cup. The therapy department indicated the resident needed two handle cups to hold the cup better. She would need to talk with management because the facility would need to order the cup. During an observation, on 2/5/25 at 8:33 a.m., Resident 1 was in the dining room eating her meal without assistance. She was noted to have milk, juice and water in two handle cups, but no coffee. During an interview,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure documentation was complete and accurately reflected the care provided for 2 of 2 residents reviewed for accurate documentation. (Resident 46 and 1) Findings include: 1. The clinical record for Resident 46 was reviewed on 2/5/25 at 10:19 a.m. The diagnoses included, but were not limited to, insomnia, chronic kidney disease, and fever. A physician's order, initiated on 1/3/25, indicated to give Dayvigo (a medication used to treat insomnia) 10 milligrams at bedtime for insomnia. Documentation of the administration of the medication was not charted on 1/10/25 and 1/25/25. A physician's order, initiated on 1/3/25, indicated to monitor the resident's vital signs twice a day. Documentation of the treatment was not charted on the Medication and Treatment record for 1/31/25 for the second shift. 2. The clinical record for Resident 1 was reviewed on 2/5/25 at 8:53 a.m. The diagnoses included, but were not limited to, weakness, heart failure, and a need for assistance with personal care. A physician's order, initiated on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated and a physician's order for oxygen was obtained for 4 of 5 residents reviewed for respiratory care. (Residents 6, 41, 206 and 10). Findings include: 1. During an observation, on 1/11/24 at 1:53 p.m., the oxygen tubing and humidifier bottle for Resident 6 was not dated. The record for Resident 6 was reviewed on 1/16/24 at 10:23 a.m. Diagnoses included, but were not limited to, shortness of breath, history of acute respiratory failure with hypoxia, and unspecified congestive heart failure. A current order, with a start date of 11/2/23, indicated to change and date oxygen tubing and humidifier bottle in the evenings every Wednesday. During an interview, on 1/11/24 at 2:46 p.m., the Clinical Support Nurse indicated the oxygen tubing was not dated. 2. During an observation, on 1/11/24 at 2:38 p.m., Resident 41 was wearing oxygen, and the oxygen tubing was not dated. The record for Resident 41 was reviewed on 1/16/24 at 9:22 a.m. Diagnoses included, but were not limited to, chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the bed hold policy was provided to the resident and/or responsible party at the time of the hospital transfer for 1 of 1 resident reviewed for hospitalization. (Resident 54) Finding includes: The record for Resident 54 was reviewed on 1/18/24 at 2:34 p.m. Diagnoses included, but were not limited to, acute respiratory failure, congestive heart failure (CHF), atrial fibrillation, atherosclerotic heart disease of native coronary artery (a narrowing of the artery), hypertensive heart, and chronic kidney disease. A nursing progress note dated 11/16/23 at 10:41 a.m., Licensed Practical Nurse (LPN) 2 indicated the resident had an oxygen saturation of 65 to 78 percent on 4 liters of oxygen. The resident was tired with rapid breathing, shaking, and back pain. The Nurse Practitioner was called, and an order was received to send the resident to the hospital for evaluation. The resident's daughter who was also the resident's power of attorney was called and updated on the resident's condition and the order to transfer the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident with compression gloves had a physician's order, a care plan and staff were educated on the use of the compression gloves for 1 of 2 residents reviewed for edema (Resident B), and failed to ensure an unlicensed staff member did not move a resident before reporting an incident and having the resident assessed for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: 1. During an observation, on 1/11/24 at 12:09 p.m., the Resident B was noted to have edema in his hands with compression gloves on both hands. During an observation, on 1/16/24 at 2:29 p.m., the resident did not have compression gloves on his hands. His bilateral hands are edematous. The clinical record for Resident B was reviewed on 1/16/24 at 11:23 a.m. The diagnoses included, but were not limited to, paroxysmal atrial fibrillation, type 2 diabetes mellitus with neuropathy, and idiopathic peripheral autonomic neuropathy. There was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to notify the physician of a significant weight change and a 5 pound or more weight gain per the physician's orders for 2 of 3 residents reviewed for nutrition. (Resident D and 26) Findings include: 1. The record for Resident D was reviewed on 1/16/24 at 2:29 p.m. Diagnoses included, but were not limited to, muscle weakness, pain, anxiety disorder, and depression. A care plan indicated the resident was at nutrition risk. The interventions included, but were not limited to, monitor weights as ordered. The resident had the following weights: 1. On 10/22/23, the resident's weight was 109.0 pounds. 2. On 1/8/24, the resident's weight was 95.0 pounds. The resident had a 12.84% weight loss in 3 months. There was no documentation of the physician being notified of the significant weight loss. A nursing progress note, dated as a late entry on 1/16/24 at 1:00 p.m., indicated the Assistant Director of Nursing (ADON) discussed the resident's weight loss and no new orders were received. During an interview, on 1/16/24 at 4:35 p.m., the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.